2000 Behavioral Risk Factor Surveillance Survey Questionnaire
Health Status
1. Would you say that in general your health is:
a. Excellent
b. Very good
c. Good
d. Fair
e. Poor
f. Don’t know/not sure
g. Refused
2. Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?
a. Number of days
b. None
c. Don’t know/not sure
d. Refused
3. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
a. Number of days
b. None
c. Don’t know/not sure
d. Refused
4. During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?
a. Number of days
b. None
c. Don’t know/not sure
d. Refused
5. Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?
a. Yes
b. No
c. Don’t know/not sure
d. Refused
6. Medicare is a coverage plan for people 65 or over and for certain disabled people. Do you have Medicare?
a. Yes
b. No
c. Don’t know/not sure
d. Refused
7. What type of health care coverage do you use to pay for most of your medical care?
a. Your employer
b. Someone else’s employer
c. A plan that you or someone else buys on your own
d. Medicare
e. Medicaid or Medical Assistance
f. The military, CHAMPUS, TriCare, or the VA
g. The Indian Health Service
h. Some other source
i. None
j. Don’t know/not sure
k. Refused
8. There are some types of coverage you may not have considered. Please tell me if you have any of the following: Coverage through:
a. Your employer
b. Someone else’s employer
c. A plan that you or someone else buys on your own
d. Medicare
e. Medicaid or Medical Assistance
f. The military, CHAMPUS, TriCare or the VA
g. The Indian Health Service
h. Some other source
i. None
j. Don’t know/not sure
k. Refused
9. During the past 12 months, was there any time that you did not have any health insurance or coverage?
a. Yes
b. No
c. Don’t know/not sure
d. Refused
10. About how long has it been since you had health care coverage?
a. Within the past 6 months (1 to 6 months ago)
b. Within the past year (6 to 12 months ago)
c. Within the past 2 years (1 to 2 years ago)
d. Within the past 5 years (2 to 5 years ago)
e. 5 or more years ago
f. Don’t know/not sure
g. Never
h. Refused
11. Was there a time during the last 12 months when you needed to see a doctor, but could not because of the cost?
a. Yes
b. No
c. Don’t know/not sure
d. Refused
12. About how long has it been since you last visited a doctor for a routine checkup?
a. Within the past year
b. Within the past 2 years (1 to 2 years ago)
c. Within the past 5 years (2 to 5 years ago)
d. 5 or more years ago
e. Don’t know/not sure
f. Never
g. Refused
13. Did a doctor ever tell you that you had asthma?
a. Yes
b. No
c. Don’t know/Not sure
d. Refused
14. Do you still have asthma?
a. Yes
b. No
c. Don’t know/Not sure
d. Refused
14. Have you ever been told by a doctor that you have diabetes?
a. Yes
b. Yes, but female told only during pregnancy
c. No
d. Don’t know/not sure
e. Refused
15. There are situations where people provide regular care or assistance to a family member or friend who is elderly or has a long-term illness or disability. During the past month, did you provide any such care or assistance to a family member or friend who is 60 years of age or older?
a. Yes
b. No
c. Don’t know/not sure
d. Refused
16. Who would you call to arrange short or long-term care in the home for an elderly relative or friend who was no longer able to care for themselves?
a. Relative or friend
b. Would provide care myself
c. Nursing home
d. Home health service
e. Personal physician
f. Area Agency on Aging
g. Hospice
h. Hospital nurse
i. Minister/priest/rabbi
j. Other
k. Don't know who to call
l. Refused
17. During the past month, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?
a. Yes
b. No
c. Don’t know/Not sure
d. Refused
18. What type of physical activity or exercise did you spend the most time doing during the past month?
Activity [specify]
Refused
19. How far did you usually walk/run/jog/swim?
Miles and tenths
Don’t know/Not sure
Refused
20. How many times per week or per month did you take part in this activity during the past month?
a. Times per week
b. Times per month
c. Don’t know/Not sure
d. Refused
21. And when you took part in this activity, for how many minutes or hours did you usually keep at it?
a. Hours and minutes
b. Don’t know/Not sure
c. Refused
22. Was there another physical activity or exercise that you participated in during the last month?
a. Yes
b. No
c. Don’t know/Not sure
d. Refused
23. What other type of physical activity gave you the next most exercise during the past month?
Activity [specify]
Refused
24. How far did you usually walk/run/jog/swim?
Miles and tenths
Don’t know/Not sure
Refused
25. How many times per week or per month did you take part in this activity?
a. Times per week
b. Times per month
c. Don’t know/Not sure
d. Refused
26. And when you took part in this activity, for how many minutes or hours did you usually keep at it?
Hours and minutes
Don’t know/Not sure
Refused
Tobacco Use
27. Have you smoked at least 100 cigarettes in your entire life?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
28. Do you now smoke cigarettes everyday, some days, or not at all?
a. Everyday
b. Some days
c. Not at all
d. Refused
29. On the average, about how many cigarettes a day do you now smoke?
a. (Number of cigarettes)
b. Don't know/Not sure
c. Refused
30. On the average, when you smoked during the past 30 days, about how many cigarettes did you smoke a day?
a. (Number of cigarettes)
b. Don't know/Not sure
c. Refused
31. During the past 12 months, have you quit smoking for 1 day or longer?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
32. About how long has it been since you last smoked cigarettes regularly, that is, daily?
a. Within the past month (0 to 1 month ago)
b. Within the past 3 months (1 to 3 months ago)
c. Within the past 6 months (3 to 6 months ago)
d. Within the past year (6 to 12 months ago)
e. Within the past 5 years (1 to 5 years ago)
f. Within the past 15 years (5 to 15 years ago)
g. 15 or more years ago
h. Don't know/Not sure
i. Never smoked regularly
j. Refused
33. How often do you drink fruit juices such as orange, grapefruit or tomato?
a. Per day
b. Per week
c. Per month
d. Per year
e. Never
f. Don’t know/Not sure
g. Refused
33. Not counting juice, how often do you eat fruit?
a. Per day
b. Per week
c. Per month
d. Per year
e. Never
f. Don’t know/Not sure
g. Refused
34. How often to you eat green salad?
a. Per day
b. Per week
c. Per month
d. Per year
e. Never
f. Don’t know/Not sure
g. Refused
35. How often do you eat potatoes not including french fries, fried potatoes, or potato chips?
a. Per day
b. Per week
c. Per month
d. Per year
e. Never
f. Don’t know/Not sure
g. Refused
36. How often do you eat carrots?
a. Per day
b. Per week
c. Per month
d. Per year
e. Never
f. Don’t know/Not sure
g. Refused
36. Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat?
a. Per day
b. Per week
c. Per month
d. Per year
e. Never
f. Don’t know/Not sure
g. Refused
37. Are you now trying to lose weight?
a. Yes
b. No
c. Don’t know/Not sure
d. Refused
38. Are you now trying to maintain your current weight, that is to keep from gaining weight?
a. Yes
b. No
c. Don’t know/Not sure
d. Refused
39. Are you eating either fewer calories or less fat to lose weight/keep from gaining weight?
a. Yes, fewer calories
b. Yes, less fat
c. Yes, fewer calories and less fat
d. No
e. Don’t know/Not sure
f. Refused
40. Are you using physical activity or exercise to lose weight/keep from gaining weight?
a. Yes
b. No
c. Don’t know/Not sure
d. Refused
41. In the past 12 months, has a doctor, nurse, or other health professional given you advice about your weight?
a. Yes, lose weight
b. Yes, gain weight
c. Yes, maintain current weight
d. No
e. Don’t know/Not sure
f. Refused
Demographics
42. What is your age?
a. Code age in years
b. Don't know/Not sure
d. Refused
43. What is your race?
a. White
b. Black
c. Asian, Pacific Islander
d. American Indian, Alaska Native
or
e. Other: _____________________
f. Don't know/Not sure
g. Refused
44. Are you of Spanish or Hispanic origin?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
45. Are you:
a. Married
b. Divorced
c. Widowed
d. Separated
e. Never been married
or
f. A member of an unmarried couple
g. Refused
46. How many children live in your household who are:
a. less than 5 years old?
b. 5 through 12 years old?
c. 13 through 17 years old?
d. None
e. Refused
47. What is the highest grade or year of school you completed?
a. Never attended school or only attended kindergarten
b. Grades 1 through 8 (Elementary)
c. Grades 9 through 11 (Some high school)
d. Grade 12 or GED (High school graduate)
e. College 1 year to 3 years (Some college or technical school)
f. College 4 years or more (College graduate)
g. Refused
48. Are you currently:
a. Employed for wages
b. Self-employed
c. Out ow work for more than 1 year
d. Out of work for less than 1 year
e. Homemaker
f. Student
g. Retired
or
h. Unable to work
i. Refused
49. Is your annual household income from all sources:
a. Less than $25,000 ($20,000 to less than $25,000)
b. Less than $20,000 ($15,000 to less than $20,000)
c. Less than $15,000 ($10,000 to less than $15,000)
d. Less than $10,000
e. Less than $35,000 ($25,000 to less than $35,000)
f. Less than $50,000 ($35,000 to $75,000)
h. $75,000 or more
i. Don't know/Not sure
j Refused
50. Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?
a. Yes
b. No
c. Don’t know/Not sure
d. Refused
51. Which of the following best describes your current military status?
a. Currently on active duty
b. Currently in reserves
c. No longer in military service
d. Don’t know/Not sure
e. Refused
52. In the past 12 months have you received some or all of your health care from VA facilities?
a. Yes, all of my health care
b. Yes, some of my health care
c. No, no VA health care received
d. Don’t know/Not sure
e. Refused
53. About how much do you weigh without shoes?
a. (Weight)
b. Don't know/Not sure
c. Refused
54. About how tall are you without shoes?
a. (Height)
b. Don't know/Not sure
c. Refused
55. What county do you live in?
a. (FIPS county code)
b. Don't know/Not sure
c. Refused
56. Do you have more than one telephone number in your household?
a. Yes
b. No
c. Refused
57. How many residential telephone numbers do you have?
a. Total telephone numbers
b. Refused
58. Indicate sex of respondent: male or female.
Women's Health
58. A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
59. How long has it been since you had your last mammogram?
a. Within the past year (1 to 12 months ago)
b. Within the past 2 years (1 to 2 years ago)
c. Within the past 3 years (2 to 3 years ago)
d. Within the past 5 years (3 to 5 years ago)
e. 5 or more years ago
f. Don't know/Not sure
g. Refused
60. Was your last mammogram done as part of a routine checkup, because of a breast problem other than cancer, or because you've already had breast cancer?
a. Routine checkup
b. Breast problem other than cancer
c. Had breast cancer
d. Don't know/Not sure
e. Refused
61. A clinical breast exam is when a doctor, nurse, or other health professional feels the breast for lumps. Have you ever had a clinical breast exam?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
62. How long has it been since your last breast exam?
a. Within the past year (1 to 12 months ago)
b. Within the past 2 years (1 to 2 years ago)
c. Within the past 3 years (2 to 3 years ago)
d. Within the past 5 years (3 to 5 years ago)
e. 5 or more years ago
f. Don't know/Not sure
g. Refused
63. Was your last breast exam done as part of a routine checkup, because of a breast problem other than cancer, or because you've already had breast cancer?
a. Routine checkup
b. Breast problem other than cancer
c. Had breast cancer
d. Don't know/Not sure
e. Refused
64. A Pap smear is a test for cancer of the cervix. Have you ever had a Pap smear?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
65. How long has it been since you had your last Pap smear?
a. Within the past year (1 to 12 months ago)
b. Within the past 2 years (1 to 2 years ago)
c. Within the past 3 years (2 to 3 years ago)
d. Within the past 5 years (3 to 5 years ago)
e. 5 or more years ago
f. Don't know/Not sure
g. Refused
66. Was your last Pap smear done as part of a routine exam, or to check a current or previous problem?
a. Routine exam
b. Check current or previous problem
c. Other
d. Don't know/Not sure
e. Refused
67. Have you had a hysterectomy?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
68. To your knowledge, are you now pregnant?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
HIV/AIDS
69. If you had a child in school, at what grade do you think he or she should begin receiving education in school about HIV infection and AIDS?
a. Grade
b. Kindergarten
c. Never
d. Don't know/Not sure
e. Refused
70. If you had a teenager who was sexually active, would you encourage him or her to use a condom?
a. Yes
b. No
c. Would give other advice
d. Don't know/Not sure
e. Refused
71. What are your chances of getting infected with HIV, the virus that causes AIDS?
a. High
b. Medium
c. Low
or
d. None
e. Not applicable
f. Don't know/Not sure
g. Refused
72. Have you donated blood since March 1985?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
73. Have you donated blood in the past 12 months?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
74. Except for tests you may have had as part of blood donations, have you ever been tested for HIV?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
75. Have you ever been tested for HIV?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
76. Not including your blood donations, have you been tested for HIV in the past 12 months?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
77. Have you been tested for HIV in the past 12 months?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
78. What was the main reason you had your last test for HIV?
a. For hospitalization or surgical procedure
b. To apply for health insurance
c. To apply for life insurance
d. For employment
e. To apply for a marriage license
f. For military induction or military service
g. For immigration
h. Just to find out if you were infected
i. Because of referral by a doctor
j. Because of pregnancy
k. Referred by your sex partner
l. Because it was part of a blood donation process
m. For routine checkup
n. Because of occupational exposure
o. Because of illness
p. Because I am at risk for HIV
q. Other
r.. Don't know/Not sure
s. Refused
79. Where did you have your last test for HIV?
a. Private doctor, HMO
b. Blood bank, plasma center, Red Cross
c. Health department
d. AIDS clinic, counseling, testing site
e. Hospital, emergency room, outpatient clinic
f. Family planning clinic
g. Prenatal clinic, obstetrician's office
h. Tuberculosis clinic
i. STD clinic
j. Community health clinic
k. Clinic run by employer
l. Insurance company clinic
m. Other public clinic
n. Drug treatment facility
o. Military induction or military service site
p. Immigration site
q. At home, home visit by nurse or health worker
r. At home using self-sampling kit
s. In jail or prison
t. Other
u. Don't know/Not sure
v. Refused
80. Did you receive the results of your last test?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
81. Did you receive counseling or talk with a health care professional about the results of your test?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
1. How old were you when you were told you have diabetes?
Code age in years
Don’t know/Not sure
Refused
2. Are you now taking insulin?
a. Yes
b. No
c. Refused
3. Are you now taking diabetes pills?
a. Yes
b. No
c. Don’t know/Not sure
d. Refused
4. About how often do you check your blood for glucose or sugar? Include times when checked by a family member or friend, but do not include times when checked by a health professional.
a. Times per day
b. Times per week
c. Times per month
d. Times per year
e. Never
f. Don’t know/Not sure
g. Refused
5. About how often do you check your feet for any sores or irritations? Include times when checked by a family member or friend, but do not include times when checked by a health professional.
a. Times per day
b. Times per week
c. Times per month
d. Times per year
e. Never
f. No feet
g. Don’t know/Not sure
h. Refused
6. Have you ever had any sores or irritations on your feet that took more than four weeks to heal?
a. Yes
b. No
c. Don’t know/Not sure
d. Refused
7. About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?
a. Number of times
b. None
c. Don’t know/Not sure
d. Refused
8. A test for hemoglobin “A one C” measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for hemoglobin “A one C”?
a. Number of times
b. None
c. Never heard of hemoglobin “A one C” test
d. Don’t know/Not sure
e. Refused
9. About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?
a. Number of times
b. None
c. Don’t know/Not sure
d. Refused
10. When was the last time you had an eye exam in which the pupils were dilated? This would have made you temporarily sensitive to bright light.
a. Within the past month (0-1 month ago)
b. Within the past year (1-12 months ago)
c. Within the past 2 years (1-2 years ago)
d. 2 or more years ago
e. Never
f. Don’t know/Not sure
g. Refused
11. Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?
a. Yes
b. No
c. Don’t know/Not sure
d. Refused
12. Have you ever taken a course or class in how to manage your diabetes yourself?
a. Yes
b. No
c. Don’t know/Not sure
d. Refused
1. What is the main reason you are without health care coverage?
a. Lost job or changed employers
b. Spouse or parent lost job or changed employers
c. Became divorced or separated
d. Spouse or parent died
e. Became ineligible because of age or because left school
f. Employer doesn’t offer or stopped offering coverage
g. Cut back to part time or became temporary employee
h. Benefits from employer or former employer ran out
i. Couldn’t afford to pay the premiums
j. Insurance company refused coverage
k. Lost Medicaid or Medial Assistance eligibility
l. Other
m. Don’t know/Not sure
n. Refused
2. Is there one particular clinic, health center, doctor’s office, or other place that you usually go to if you are sick or need advice about your health?
a. Yes
b. More than one place
c. No
d. Don’t know/Not sure
e. Refused
3. Is there one of these places that you go to most often when you are sick or need advice about your health?
a. Yes
b. No
c. Don’t know/Not sure
d. Refused
4. What kind of place is it? Would you say
a. A doctor’s office or HMO
b. A clinic or health center
c. A hospital outpatient department
d. A hospital emergency room
e. An urgent care center
f. Some other kind of place
g. Don’t know/Not sure
h. Refused
5. Do you have one person you think of as your personal doctor or health care provider?
a. Yes, only one
b. More than one
c. No
d. Don’t know/Not sure
e. Refused
Module 13: Cardiovascular Disease
1. To lower your risk of developing heart disease or stroke, has a doctor advised you to
a. Eat fewer high fat or high cholesterol foods
b. Exercise more
2. To lower your risk of developing heart disease or stroke, are
a. Eating fewer high fat or high cholesterol foods?
b. Exercising more?
3. Has a doctor ever told you that you had any of the following?
a. Heart attack or myocardial infarction
b. Angina or coronary heart disease
c. Stroke
4. Do you take aspirin daily or every other day?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
5. Do you have a health problem or condition that makes taking aspirin unsafe for you?
a. Yes, not stomach related
b. Yes, stomach problems
d. No
6. Why do you take aspirin?
a. To relieve pain
b. To reduce the chance of a heart attack
c. To reduce the chance of a stroke
7. Have you gone through or are you now going through menopause?
a. Yes, have gone through menopause
b. Yes, now going through menopause
c. No
d. Don't know/Not sure
e. Refused
8. Estrogens such as Premarin and progestins such as Provera are female hormones that may be prescribed around the time of menopause, after menopause, or after a hysterectomy. Has your doctor discussed the benefits and risks of estrogen with you?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
9. Other than birth control pills, has your doctor ever prescribed estrogen pills for you?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
10. Are you currently taking estrogen pills?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
11. Why
a. To prevent a heart attack
b. To treat or prevent bone thinning, bone loss, or osteoporosis
c. To treat symptoms of menopause such as hot flashes
1. During the past 12 months, have you had pain, aching, stiffness or swelling in or around a joint?
a. Yes
b. No
c. Don’t know/Not sure
d. Refused
2. Were these symptoms present on most days for at least one month?
a. Yes
b. No
c. Don’t know/Not sure
d. Refused
3. Are you now limited in any way in any activities because of joint symptoms?
a. Yes
b. No
c. Don’t know/Not sure
d. Refused
4. Have you ever been told by a doctor that you have arthritis?
a. Yes
b. No
c. Don’t know/Not sure
d. Refused
5. What type of arthritis did the doctor say you have?
a. Osteoarthritis/degenerative arthritis
b. Rheumatism
c. Rheumatoid Arthritis
d. Lyme disease
e. Other [specify]
f. Never saw a doctor
g. Don’t know/Not sure
h. Refused
6. Are you currently being treated by a doctor for arthritis?
a. Yes
b. No
c. Don’t know/Not sure
d. Refused
Module 13: Folic Acid
1. Do you currently take any vitamin pills or supplements?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
2. Are any of these a multivitamin?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
3. Do any of the vitamin pills or supplements you take contain folic acid?
a. Yes
b. No
c. Don't know/Not sure
d. Refused
4. How often do you take this vitamin pill or supplement?
a. (Times per day)
b. (Times per week)
c. (Times per month)
d. Don't know/Not sure
e. Refused
5. Some health experts recommend that women take 400 micrograms of the B vitamin folic acid, for which one of the following reasons
a. To make strong bones
b. To prevent birth defects
c. To prevent high blood pressure
or
d. Som other reason
e. Don't know/Not sure
e. Refused
1. In the past 30 days has anyone, including yourself, smoked cigarettes, or pipes anywhere inside your home?
a. Yes
b. No
c. Don’t know/Not sure
d. Refused
2. While working at your job, are you indoors most of the time?
a. Yes
b. No
c. Don’t know/Not sure
d. Refused
3. Which of the following best describes your place of work’s official smoking policy for indoor public or common areas, such as lobbies, rest rooms, and lunch rooms?
a. Not allowed in any public areas
b. Allowed in some public areas
c. Allowed in all public areas
d. No official policy
e. Don’t know/Not sure
f. Refused
4. Which of the following best describes your place of work’s official smoking policy for work areas?
a. Not allowed in any work areas
b. Allowed in some work areas
c. Allowed in all work areas
d. No official policy
e. Don’t know/Not sure
f. Refused
5. In the following locations, do you think that smoking should be allowed in all areas, some areas, not allowed at all?
a. Restaurants
b. Schools
c. Day care centers
d. Indoor work areas
6. Has a doctor or other health professional ever advised you to quit smoking?
a. Yes, within the past 12 months (1-12 months ago)
b. Yes, within the past 3 years (1-3 years ago)
c. Yes, 3 or more years ago
d. No
e. Don’t know/Not sure
f. Refused